Insurance Codes – Billing Rules tab
Use this tab to specify the settings for the patient’s authorizations, claim generation, and claim details on the insurance code level. Here you can select billing methods for Late and CSP claims, set CSP billing rules, define the active payers order in the payers chain, and define additional parameters for the plain form with logo. Complete the following sections as appropriate to your agency.
Authorizations
Select the following authorization settings:
- Require Authorizations – Select to require authorizations settings for the selected insurance (there must be an authorization defined for the insurance). If authorization is not defined for the insurance, an error message appears to the effect of not allowing you to schedule a visit.
- The 'Can Exceed Authorized Visits' security privilege allows you to override the message and schedule the visit.
- Include Non-Billable – Include non-billable services into authorizations calculation: non-billable services and usual billable services are allowed for calculation.
- Consolidate Claims Across Authorizations – Allocate the authorization records across the claim based on the authorization number so that one claim is produced for all services provided based on the claim date range. If this check box is selected, every three authorization records are printed on a single page with the authorization number in the 63 locator and authorization details on the claim. Nonauthorized and pending services are printed on separate pages with the 63 locator empty and with details for nonauthorized services. For example, if there are four visits with authorization for each, the first three visits are printed on one page, and one visit is printed on another page. Clear the Consolidate Claims Across Authorizations check box to generate single authorization records with the corresponding services on a separate page. Nonauthorized and pending services are also printed on separate pages with the 63 locator empty and with details for nonauthorized services.
- If you are a commercial PPS payer, do not select the Consolidate Claims Across Authorizations check box. This option is unavailable in Administration > Financial > Insurance Codes and should not be selected in Administration > Financial > Insurance Companies.
- Allow Overlapping – Allow multiple authorizations with overlapping dates. If the check box is clear, the error message appears in Patient > General > Authorizations that you are not allowed to enter the authorizations with overlapping dates.
- Allow Contractor Services – Allow entry of contractor services for the authorization. If this check box is selected and the contractor resources enter services, they are included in the authorization record and can enter and define parameters for the contractor disciplines in the authorization details. Leave the Allow Contractor Services check box clear to allow only staff roles. Only staff services are considered while defining the authorization.
If you are changing existing information in the Require Authorizations, Include Non-Billable, and Allow Contractor Services boxes, a message displays that your changes affected authorizations. You must run the Recalculate Authorizations utility in Administration > Maintenance for the existing services to reflect recent changes.
Claim Generation
The following windows in Administration > Financial are used to set up claim processing and printing:
- Insurance Codes
- Insurance Companies
- Insurance Companies > Plans
If the Plan, Insurance Company, or Insurance Code is specified in the Payers window, the priority settings are considered in descending order. For example, if the Plans tab has the Billing Rules check box selected and the Payers window contains the Plan specified, the Plans tab takes priority.
When selecting a billing rule, open claims are not affected automatically. To recalculate any open claims, run the Recalculate Claims function in Administration > Maintenance. New claims are generated according to the selected billing rules for late billings.
You can select the appropriate billing rules for claim generation. Billing rules are available depending on the payer mode.
| Billing Rule | Description |
|---|---|
|
FFS – Include PPS HIPPS |
Include the HIPPS code for the Fee-for-Service payers in the printed claim. The HIPPS code is displayed in the first line of the FFS claim (UB-04). The information is displayed in the OASIS Scores dialog for PPS payers, and the HIPPS is stored for inclusion on the FFS claim. This option requires that the episode length for the insurance is 60 days. This billing rule applies to regular payers. |
|
Services resolved |
Generate the final claim when all services are verified (V) or unmade (U). The claim is not generated if services are scheduled (S) or in-process (I) statuses. |
|
Supplies resolved |
Generate the final claim when all supplies are verified (V). |
|
Certification orders signed |
The Scheduled Orders check box must be selected in Administration > General > Patient Classes. At least one certification order must exist. The physician must sign all existing certification orders within the patient’s active certification period covering the claim’s date range. For episodic payers, generate the final claim when the physician signs the certification order on the episode start date. This rule is unavailable for CSP, Eligible CSP, and Bereavement payers. |
|
Supplemental orders signed: |
Generate the final claim if all verified supplemental orders are signed. |
| OASIS is exported for the Episodic final claim | Generate the final claim if all OASIS assessments have been exported for the patient. |
|
Physician is PECOS enrolled |
For Medicare or Medicare Advantage Home Health claims:
For Medicare Benefit Hospice claims with a From Date on or after 05/01/2024:
|
|
CTI documents signed |
Generate claims when CTI documents that cover each day of the generated claim are signed for the particular admission. The billing rule checks the status of CTI documents, and if it is set to Signed, then claims are available for processing. Otherwise, claims are not available, and the Claim Alerts report displays what claims and why they cannot be processed. You can check the status of CTI documents in Transactions > General > Process Signed Documents. This rule is available for B (Benefit) and H (Hybrid) insurance modes. |
|
F2F document signed |
Generate claims when a face-to-face document is signed for admission. The billing rule checks the encounter type and status of the face-to-face document on the Encounter Information tab. The claim is available for processing in the following cases:
In other cases, a claim is unavailable, and the Claim Alerts report shows such claims—you can check the status of face-to-face documents in Transactions > General > Process Signed Documents. This rule is available for R (Regular) and P (Episodic) insurance modes. |
Claim details
In this section, select the following claim details settings for payers.
- WI Medicaid - Split service based on shift modifier – Split services according to the time they were provided. This check box is active for business units where the state is defined as Wisconsin and the Wisconsin Medicaid Home Health specialized format is selected on the Print Variations tab. This option is not selected by default, and services are not split. Select this check box to split services and set up shift modifiers in the Billing Rates window.
- Update Non-Billable Data in Closed Claims – Update closed and void claims with non-billable field changes, if any. Claims are updated after you run the Recalculate Claims option. For the list of all non-billable fields, see Non-Billable Fields.
- If you do not want to update any non-billable data affecting closed or void claims, clear this check box.
- Report Q codes on Final claim for episodes starting from – Select this check box and specify the date on or after July 1, 2013, to report on the Home Health PPS claims the location where the first billable service was provided.
- If the patient’s facility is changed during the episode, then an additional service line with the new type of service location (Q code) and the nominal charge of 1 cent is added.
- The following Q codes must be defined for the appropriate resource types in the HCPCS Code for Specific Resource Type window that opens when clicking the ellipsis button in the H.R. column in Administration > Financial > Billing Rates > Rates:
- Q5001 – Hospice or home health care provided in patient’s home/residence.
- Q5002 – Hospice or home health care provided in an assisted living facility.
- Q5009 – Hospice or home health care provided in place not otherwise specified (NOS).
- If the patient’s facility is not defined, then the service location code for the Home resource type is taken from the HCPCS Code for Specific Resource Type window.
- To define a service code for a location other than a home or an assisted living facility where a patient receives services (for example, hotel, shelter, and so on), see the Rates Grid.
- Important: If the service location code is changed, the closed claims are not updated automatically. You must recalculate these claims and generate void and replacement claims.
Update Non-Billable Data in Closed claims
- Select this check box or leave it shaded and selected to update the non-billable fields in closed claims. Note that before version 6.1, non-billable data were continually updated in the closed claims.
Plain Form with Logo Fields
This section is visible only for the insurances with the Plain with Logo form selected in Administration > Financial > Insurance Codes > General. In this section, select additional details to be printed on the invoice:
- To pay online, visit – Enter the web address for paying the bills online.
- Make checks payable to – Enter the name of the organization to receive the payments.
Active payers order
Some payers require all eligible payers to report a patient on electronic claims. It is the provider’s responsibility to make sure that all active eligible payers for a patient are defined in the Pay Source section in Patient > General > Payers; they may not necessarily be specified in the Pay Control section or the Payers Denial Information window (in Patient > General).
If a payer is no longer actively eligible, enter the end date in the Effective Periods column in Patient > General > Payers > Pay Source. Review and update these payers accordingly before every claim submission to ensure accuracy.
For the payers that require reporting of all eligible payers electronically (up to 11 active insurances), select the Report Other Payers check box. You can select the Report Other Payers check box only for the appropriate payer with this requirement and not necessarily for all the patient's payers.
The active payer's order may be defined in the following locations:
- Administration > Financial > Insurance Companies > Plans > Billing Rules
- Administration > Financial > Insurance Companies > Billing Rules
- Administration > Financial > Insurance Codes > Billing Rules
The active payer's order to be used depends on where it was set up according to the hierarchy system listed above. If an order is not defined at the highest level, the application checks the next lower level for an active payer's order and continues until the lowest level in the hierarchy is reached, which is the active payer's order as defined on the Billing Rules tab in Administration > Financial > Insurance Codes.
When you select the Report Other Payers check box, the default sequence of other payers is defined: Medicare payers are set as primary, Commercial as secondary, and Medicaid as tertiary. You can change this order by selecting the appropriate payer type in the Primary, Secondary, and Tertiary fields. When all fields in the Active Payers Order section are complete, the active payers listed in the payer’s eligibility system are reported in the electronic claims and the CSP payers that previously adjudicated the claim. Only the payers with Active pay source status are included in the list according to their effective periods. The payers with identical insurance IDs are not duplicated. All claims generated or regenerated after you select the Report Other Payers check box include the payers listed.
Before generating and submitting the 5010 electronic claim files, ensure that all payers listed in the payer’s eligibility system have been entered. If the Report Other Payers check box is selected in the Active Payer Order section, then in the new 5010 templates of Min 7.1.3.140 version, the active payers are reported in the 2320 loop of electronic claims together with the CSP payers that previously adjudicated the claim. The payers are listed in the defined order, and the position of every insurance is shown in the SBR01 segment using the following codes:
- P – Primary
- S – Secondary
- T – Tertiary
- A – Payer Responsibility Four
- B – Payer Responsibility Five
- C – Payer Responsibility Six
- D – Payer Responsibility Seven
- E – Payer Responsibility Eight
- F – Payer Responsibility Nine
- G – Payer Responsibility Ten
- H – Payer Responsibility Eleven
If the payers are not listed as CSP payers and, therefore, have not been billed, then the 2430 Loop is not reported, and the following segments are not shown in the 2320 Loop for the payers:
- CAS – Claim Level Adjustments
- AMT – COB Payer Paid Amount
- AMT – Remaining Patient Liability
- DTP – Date - Claim Check or Remittance Date
Instead, the AMT - Total Non-Covered Amount segment is written with the A8 qualifier in AMT01 and the amount from CLM02 - Total Claim Charge Amount in AMT02 (for example, AMT*A8*500~).
All fields in the Active Payers Order section must be completed to create a list of other payers. The exact value cannot be selected in several fields. The list of payers is reported only in electronic claims; this functionality does not impact hardcopy claim printing.
- Exceptions:
- If the Report Other Payers check box is selected in the Active Payers Order section, its logic takes priority over the logic for reporting value codes as adjustments. Therefore, if you want to report the A1, A2, B1, B2, C1, and C2 value codes as adjustments, ensure that the payer is previously billed or that the Report Other Payers check box is clear at any of the levels where this billing rule exists for the claim. Due to the 5010 requirements, the different segments for these two situations cannot coexist for the same payer.
- Some payers indicated they expect CAS adjustment segments to be reported for eligible payers. In this case, the Report Other Payers check box does not work for that payer because the system does not report the CAS segment, as explained above. The provider must bill all eligible payers within the application for those payers to adjudicate the claim and return an adjustment amount, even if it is for the entire claim amount.
Late and CSP
This section contains the following fields:
Billing Method for Late
- Select the billing method for late charges for this insurance code. Services are considered 'late' when the original claim has already been billed.
- Late charges are billed using the following options:
- 5 – Generate 815s, 825s, or 335s for late charges – The system generates a late claim with a type of bill (located in FL 4 of the hardcopy UB-04 claim form) position three as 5. For example, Home Health claims start with either 33 or 32; the last digit on the late claim would be a 5 (335/325). Hospice claims begin with 81 or 82 and have a five as the third digit when a bill is generated for additional services (815/825).
- V – Void previous bill and generate replacement bills with late charges – The system voids the original claim and generates a replacement claim with all services for the billing period. For example, you have billed ten skilled nursing services for January, and after you have completed January billing (AR is generated), three physical therapy services are added. With this option selected, the system voids the original bill with 10 SN services and creates a replacement claim with the 10 SN visits and 3 PT services—13 services. This option is commonly selected when a payer only accepts one claim per date range (as defined in FL 6 on the UB-04 hardcopy claim).
- C – Void previous if Continuous Care otherwise generate Type 5 – This option is used only for Hospice billing. It voids the original claim only if the services added trigger the billing of continuous care (for example, before the services were added, the patient did not have enough hours for continuous care, but with the services added, the system voids and replaces the claim). If a service is added (for example, physician service), the system generates a late claim only for the additional service.
- N – Adjustments for New York Medicaid – This option is used only for the New York Medicaid insurance codes. It should be selected if your agency would like to hold the adjustment claim if the DCN number has not been entered through the Collections windows or the ERA processing. If you select this option for an insurance company that previously had another billing method defined, you receive a message that you need to recalculate open claims to reflect your changes.
Billing Method for CSP
Select the billing method to use as a contingent secondary payer for this insurance code:
- A - Bill at this pay source’s rate
- B - Bill at the original pay source’s rates
If rates of the primary and the CSP payers differ and the 'A' method is selected, the CSP claim amount can vary from the amount set up in the 'forwarded to CSP' adjustment. To avoid this, define the 'B' billing method or use the adjustment types with the active CSP Deduction option to have proper amounts on the CSP claim.
CSP Billing Rules
Select the necessary CSP billing rule for the insurance code:
- 1 - Calculate all claim amounts (gross, standard net, and actual net) and gross charges minus prior payments. The claim amounts are calculated using the following formula: claim amount = total gross charges - prior payments.
- 2 - Calculate all claim amounts (gross, standard net, and actual net) as total actual net charges minus prior payment. The claim amounts are calculated using the following formula: claim amount = total net charges - prior payments.
Prior payments also include adjustments with the CSP Deduction option selected in Administration > Financial > Adjustment Types.
If you have the CSP claims when the primary payer is Commercial PPS, billing rules do not follow the abovementioned options. For more information, see CSP Claims for Primary PPS Payers.
ICD-10
Specify when the payer is ready to report ICD-10 codes on claims. If the from date of the claim is on or after this date, then ICD-10 codes (if defined) are reported on claims.
The ICD-10 effective date may be defined in the following places in the application:
- Administration > Financial > Insurance Companies > Plans > Billing Rules
- Administration > Financial > Insurance Companies > Billing Rules
- Administration > Financial > Insurance Codes > Billing Rules
- Administration > Configuration > Organizations > Basic > Settings > Clinical
The date to be used depends on where it was set up according to the hierarchy system. For example, if the date is set up for the plan and specified in the Payers window, that date takes priority. If the date for the plan is not defined, then the date set for the insurance company is considered, and so on.
Pre-Claim Review
- Specify the date for which the Pre-Claim Review should start and end.